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boy- Fy-��l�h zc l n fa-� <br /> SAN JOAQUE.. :AUNTY PUBLIC HEALTH SERVICES/E VIRONMENTALY...,...LTH DIVISION <br /> 1 UGST WORKSHEET FOR SITE CLOSUIE EVALUATION <br /> AHE OF FACILITY C&,LL4p1/r1ECAU Cede V— 9V-'0di(.)G SWEEPS CODE JZ 3 '77- <br /> DDRESS 13 14 0 W , YVQsYit✓l fD TANK ID # �— <br /> TANK SIZE <br /> 11. GENERAL SITE HISTORY <br /> y! <br /> is permit current? es o ermit # a ility Status Code �j- oc.Soil/GW Cont es o <br /> umber of Tanks at facility be of Tanks(if available) ype of Tank teel Fbrg( ngt Dual <br /> f i I. TANK HISTORY rerVIOJ4x' G•3•$�- <br /> as Tank tested7 es 140 ailed precision test ? es 1 11 <br /> o if yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> Is repair done under inspection7 es o ere soil samples ana yzed? es _1___K TXE -G -0 /1iD8 <br /> ype of failure/discharge atastrophic tong-term teakage ver itt nknown ther: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ail Samples Received es o epth to Ground water of/Year verage Arvsual Precipitation N= 4 10-25 <br /> n-Site Welts) es o r & Type Irr I om I ub <br /> S score 5 score S 3core <br /> istance to Welts) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ondition <br /> Site Feature - Leaching potential Analysis E 's met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None 9 Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown 5resent <br /> Inigue site features: Recharge area, coarse soil, nearby wells: At least 4ore than <br /> xxxxx None one one <br /> t6ar (g 0,0UWkJ COLUMN TOTALS>>>TOTAL POINTS * :23- * 32 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> gT�X No Iib 8 T X E B T I X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ompte Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> N b @ I���r]TPH fESEL. 10,090 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contaminati.n is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 if depth is > 5 ft. and < 25 ft., score 0 points. f depth c_5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 8TX&E are not applicable at a TPH conte tration of 10 ppm (gasotine) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels YesEl <br /> 2. Recommend Site Ctosure es I a If Yes, Refer to Site Mi igation for Evatuatien { � <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE VES 0 EFERRED TO SITE MITIGATION FOR EVALUATION eES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> E-H 29 80 <br />